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February 16, 2024

Best Practices for Effective Claims Reviews in Medical Billing

Healthcare professionals, physicians, and doctors worldwide spend their lifetimes mastering their crafts in patient care and treatments. Their efforts make it possible for patients to live healthier, meaningful, and fuller lives. However, in all those years of learning, they have not taken a masterclass in processing medical claims or handling claims reviews. That in addition to not knowing how to get patients to pay their bills, leads to third-party medical billing services.

The DNA of Medical Claims Reviews

When provider practices lack the knowledge, expertise, and experience to fill out claims correctly, the insurance providers often end up rejecting such claims. The back-and-forth process of claim rejections and resubmissions costs your medical practice a lot in processing resources. Some studies even deduce that inefficient claims processing can cost you $188 on average for reworking a denied claim. The overall cycle further emphasizes adopting the best practices for effective claim reviews in medical billing.

The Impact?

Healthcare providers are now investing in claim reviews or claims scrubbing solutions to steer clear of financial and resource losses.

Improving Claims Reviews Process

As a healthcare provider, you can employ the following best practices for effective claims reviews – including:

1. Implementing Robust Software

Healthcare providers should consider investing in advanced claims scrubbing software to enhance the claims review process. Such software is vital in restructuring the process and improving overall accuracy. By employing automated algorithms, such tools can quickly detect errors and irregularities in the claims, ensuring they are error-free before submission.

2. Constant Staff Training

Another important aspect of improving the claims review process involves conducting regular training sessions for the billing staff. These sessions are essential for keeping the staff updated with the latest billing guidelines and payer requirements. A well-trained team is better equipped to identify potential errors during the claim scrubbing process and efficiently resolve any issues that may arise.
In addition to implementing robust software and providing continuous training, healthcare providers should emphasize the importance of communication and collaboration among the staff involved in the claims review process. This collaborative approach ensures that any identified issues are addressed promptly and accurately.

3. Check for Inaccurate / Inadequate Information

Identifying and Correcting Errors: Delays in claims often stem from errors. Rejections occur due to inaccuracies or errors in:

Insurance IDs
CPT codes
Addresses
Patient details
ICD codes

Note: Correcting and resubmitting rejected claims is essential.

Collecting Patient Financial Responsibility Upfront: Collect patient financial statements before treatment to avoid issues. Patients forgetting checkbooks or leaving without payment can be prevented by collecting copays during registration.
Reviewing Patient Accounts for Balances: Before adding charges, check patient accounts to collect any existing balances.
Handling Deductibles Efficiently: Collect a small upfront deposit if a deductible is verified. For patients who met their deductible elsewhere, it’s cost-effective for the insurance company to mail refund checks.

4. Performing Internal Audits

Internal audits of the claims reviews process help healthcare providers identify the following:

Error patterns
Areas for improvement
Training needs for staff

Overall, this feedback loop is key for refining the process, ensuring continuous accuracy, and maintaining compliance.

5. Utilizing Analytics for Advantage

In medical billing, insurance companies face immense pressure to enhance:

Performance
Visibility
Compliance with regulations.

Among these challenges, analytics emerge as a valuable tool. Through analytics, insurance companies can enhance performance and ensure compliance. The strategic use of analytics and automation enables:

Improvements in operations
Addresses process gaps
Boosts service quality for members

Insurance companies often face uncertainties about error sources and challenges in the current landscape.
Analytics offers a viable solution by providing the capabilities to identify common errors, manage complex claims, eliminate performance variability, reduce operating costs, and efficiently deploy skilled personnel.

6. Collaboration with Payers

Strengthening relationships with insurance payers is essential for healthcare providers seeking to understand payer-specific requirements. Regular communication and feedback exchanges lead to collaboration, minimizing claim rejections and denials. Such collaborations are necessary for maintaining a smooth and efficient claims review process in medical billing.

7. Timely Invoicing for Effective Claim Reviews

Sending patient invoices punctually is vital for successful claims reviews in medical billing. Once the explanation of benefits (EOB) is posted, the patient invoice should be dispatched immediately. This ensures higher chances of timely payment from patients.
Patient invoices should be clear and comprehensive, detailing services performed, date of service, payments received, insurance reimbursements, and any remaining balance. It’s essential to make the invoice easy to understand and provide a patient-friendly look and feel.
Moreover, consider offering convenient payment options, such as credit card payments, over the Internet, or phone payments. This speeds up the payment process, reduces costs, and saves patients the time and effort of writing and mailing a check.

Value of Eligibility Verification in RCM

Another essential aspect of effective claims reviews is recognizing the value of eligibility verification in RCM. This process ensures accurate and timely reimbursements by confirming a patient’s insurance coverage and benefits eligibility. By incorporating eligibility verification into the claims review process, healthcare providers can reduce errors, maintain compliance with regulatory guidelines, and improve operational efficiency. This contributes to a smoother billing process and enhances the trust and satisfaction of healthcare providers and patients alike.

Exploring the Benefits of Claims Scrubbing

Now that we understand what claims reviews or claims scrubbing is let’s look into its benefits:

1. Faster Payments

Most importantly, timely claim reviews speed up payments by improving the completeness and accuracy of the claims that you submit. This reduction in rejected claims ensures that your practice receives money timely reimbursements.

2. Better Cash Flow

Through faster access to cash, your practice revenue improves. Resulting in cash flow increases. This makes it easier to cover the operating expenses and invest in other areas of the practice.

3. Greater Patient Satisfaction

Ensuring every claim your team submits is accurate and on-time claims reviews lead to satisfied patients who can trust you.

4. Increased Productivity

Since claims review tools help medical practices go through the processing phase faster — and then as the claims are less likely to be denied — the investment improves your practice’s productivity. Instead of spending countless hours manually reviewing each claim or resubmitting rejected claims repeatedly, your team gets to focus on other essential facets of your business — like delivering top-notch experiences to patients every time.

Significance of Claim Scrubbing in Medical Billing

Claim scrubbing in medical billing plays its role in securing accurate and timely reimbursements for healthcare providers. Let’s explore why claim reviews are essential:

1. Minimizing Claim Denials

Firstly, claims reviews help identify and correct potential errors in claims before submission, significantly reducing the likelihood of claim denials. This ensures a steady cash flow and lessens the administrative burden of appealing denied claims.

2. Accelerating Reimbursements

Claim reviews speed up the payment cycle by restructuring the claim submission process and minimizing errors. This results in healthcare providers receiving reimbursements faster, enhancing financial stability and operational efficiency.

3. Enhancing Compliance

Claims reviews or scrubbing aids healthcare organizations in abiding by various regulatory guidelines and payer requirements. This ensures compliance with billing standards, documentation guidelines, and other key regulations, lowering the risk of audits, penalties, and legal issues.

4. Improving Operational Efficiency

Automated claim scrubbing eliminates time-consuming manual claims reviews and reduces the need for rework due to errors. It allows physicians to allocate resources more effectively, focusing on patient care and improving operational efficiency.
Incorporating claims review or scrubbing into medical billing practices is essential for minimizing errors, ensuring timely reimbursements, maintaining compliance, and enhancing operational efficiency.

Benefits for Insurance Claims

Effective claims review in medical billing brings significant benefits for insurance claims. Firstly, efficient claims reviews minimize errors, reducing the chances of claim denials. This ensures a smoother cash flow and lessens the administrative burden of appealing denied claims. Additionally, these reviews accelerate reimbursement processes, providing healthcare providers faster access to funds. Improved cash flow, in turn, enhances the financial stability of medical practices, making it easier to cover operating expenses and invest in various aspects of the business.

Conclusion

Implementing best practices in medical claims reviews is vital for efficiency. The National Health Insurer Report Card suggests potential annual savings of nearly $17 Billion by eliminating errors. While complete elimination is unrealistic, dedicated efforts can significantly reduce errors, benefitting many medical insurance users/patients. Outsourcing to expert third-party service providers addresses challenges in processing speed, accuracy, volume, compliance, and costs, improving customer satisfaction. Timely claim reviews in medical billing are necessary to ensure accuracy, compliance, and efficiency. It minimizes denials, accelerates reimbursements, and improves operational efficiency. Adopting these practices saves costs and contributes to a smoother medical insurance claims processing system.